Title: Patient Safety Escape Room - Long Term Care

Authors: ayress (Author); jlelliott (Author); Jennifer Scarfe-Brideau (Author); sumpters (Author)

Client Safety Escape Room - Long Term Care

Authors: Jennifer Scarfe-Brideau & Janice Elliott, School of Nursing, Fanshawe College,  Stephanie Ayres and Scott Sumpter, CSTAR

Learning Objectives

Upon completion of this activity you should be able to identify the following:

- Appropriate communication strategies to incorporate into care for a client with a language barrier
- The nurse’s role in delegating/assigning tasks to an Unregulated Care Provider

- The most common organism causing urinary tract infections
- The safety aspects related to urinary health in the elderly
- The most common reason for a fall in the elderly
- The prevalence of falls in the elderly and potential negative outcomes of the event
- Aspects that support the Patient Restraints Minimization Act, 2001 [Bill 85]

- Correct utilization of verbal and written communication [DAR and SBAR]
- Client centred care

Introduction

intro

Mr. Wei is a 94 year old male with Failure to Cope at home [usually co-operative, able to perform some ADL’s with cueing].  Recently admitted to Long Term Care, he only speaks limited English with Mandarin being his primary language

CP Title

Client Profile

Summit Long Term Care Home

1116 Summit Avenue, London, ON N8V 4C9

Client Profile

Name | Zhang Wei
Age | March 18th, 1927
Sex | Identifies as male
Language[s] Spoken | Mandarin Limited English Proficiency
Height | 168 CM | Weight | 67 KG
Address | 1116 Summit Avenue, London, ON
OHIP # | 87367 – 882 – 126 - AE
Diagnosis | Failure to Cope
Allergies | Penicillin
Code Status | DNR – Comfort Measures Only
SDM | Patricia Wei [Daughter] + Bao Shepard [Son]
Admission History | Client recently [02/02/21] admitted to Summit Long Term Care as unable to cope at home.  Increasing difficulty performing ADL’s. On admission - orientated to person, place and time, co-operative and able to follow directions. Admission vital signs 154/88, 88, 20, 37°C.
Medical/Surgical History | Stroke - left hemiplegia   Benign prostatic hypertrophy x 5 years – urinary retention requiring indwelling catheter Hypertension x 22 years Immunizations up to date.
Support Systems | Patricia Wei [Daughter] + Bao Shepard [Son] Nina Parsons [Family Friend] Interpreter [James Wong]
Services | Physiotherapy, Recreational Therapy, Dietary

Dr. Andrea Zeiger
Dr. Andrea Zeiger

The client has had a change in their condition.  Nurse notices something has changed with the client when performing their morning medication pass.

Changes noted in Mental Status include increased confusion, drowsiness, decreased cooperation and requiring increased direction and assistance with ADL activities.

nurse intro

Nurse:

Hi Mr. Wei, How are you this morning?

points at food tray - I see that you have not touched your meal this morning?

Credits: by ayress (Author); licence CC BY-NC-ND 3.0

[Image: male nurse with clipboard]

Credits: by ayress (Author); licence CC BY-NC 3.0

[Image: older chinese man]

client response

Client responds:

bú è, bú è

Nurse: Do you know where you are, can you tell me your name and what day of the week it is?

Client does not respond, simply shakes head.

Nurse: You seem very sleepy - are you having trouble staying awake?

[Image: older Chinese man]

client in mandarin

Client responds:

kē shuì

zǒu kāi

What strategies/tools could the nurse utilize to facilitate communication in this situation?

Click on the hotspots on the picture for more information and clues to what Mr. Wei is saying.

Communication

Credits: by ayress (Author); licence CC BY-NC-SA 3.0

Medical Interpreters - in person or by phone

You call the Medical Interpreter and they tell you that bú è means not hungry

Family/friends that can interpret

The daughter lets you know that zǒu kāi means go away.

Professional staff members who speak other languages fluently

A staff member who speaks mandarin tells you that téng tòng means pain.

Creating a communication board

[Image: pictures of common phrases]

With the communication board he points to sleepy - kē shuì

Organization sanctioned apps

Using the app you find out that nǚ ér means daughter

communication

Q: What is Mr. Wei trying to tell you?
- I am sleepy and in pain, go away (Not quite - try again)
- I am not hungry, I am tired and I want my daughter (Keep trying!)
- I am sleepy, I am not hungry, go away
- I am in pain and I am not hungry, I want my daughter (Not quite - try again!)

Delegation

Credits: by unknown (Author); licence CC BY-NC 3.0

[Image: thought bubble]

delegation

Nurse is thinking:

I am really busy so I need to delegate certain assessments to the Unregulated Care Provider and then get a report from them.  But what parts of his assessment and care can I delegate?

Delegation to UCP - drag the response to the correct box

- Providing comfort measures for the client
- Encouraging oral hydration
- Turn the client q2h
- Observe and report to the nurse oral intake
- Provide oral care
- Obtain vital signs
- Phoning report to the physician
- Assessing characteristics of urine, voiding pattern, pain, bladder palpation, and abdominal assessment
- Phoning the family to provide an update on client’s change in condition
Q: Can delegate
A: Providing comfort measures for the client; Encouraging oral hydration; Turn the client q2h; Observe and report to the nurse oral intake; Provide oral care
Q: Cannot delegate
A: Obtain vital signs; Phoning report to the physician; Assessing characteristics of urine, voiding pattern, pain, bladder palpation, …

infection location

[Image: male nurse with clipboard]

Nurse notices the mental change and needs to critically think through the situation. The nurse is considering a potential urinary tract infection [UTI].

The Medical Interpreter who speaks Mandarin talks with Mr. Wei and relays to you that he is saying:

 “I just don’t know what is wrong with me? Where am I and what am I doing here?”

From the interpreter you also understand that Mr. Wei is having back pain, is nauseated and feels chilled and shaky.

His vitals signs are:

- Temperature 37.5°C
- Blood Pressure160/90
- Heart rate 90
- Respiratory Rate 18

What is the most likely location of his UTI?

Credits: by ayress (Author); Unknown (Author); licence CC BY 3.0

[Image: picture of urinary tract with numbers in areas of the body - kidney is 9436, bladder is 4528 and urethra is 7510]

Find the corresponding number on the image for the location of infection.

Notify the physician - SBAR

Your next step is to notify the physician using SBAR.

Situation: Hello Dr. Zeiger.  It is Joe Belgrave, I am a PN caring for Zhang Wei at Summit Long Term Care Home today. Mr. Wei is a 94 year-old male who has been recently admitted to our facility with Failure to Cope. I have completed a neurological and urinary assessment. Mr. Wei’s condition has changed over the morning in relation to his alertness, mentation, and urinary function. He has communicated that he is having back pain. Complains of nausea and chills.

Background

Background: Client has Benign Prostatic Hypertrophy and has an indwelling urinary catheter to assist with urinary retention. History of left hemiplegia due to a stroke. His mentation of being alert and orientated to person, place and time has changed to drowsiness and disorientation. Urinary output per catheter is low, 100 mLs over the last 4 hours, cloudy, dark, foul smelling and blood streaked. Urinary catheter has been in place for 3 weeks. VS 37.5°C, 160/90, 90, 18.  He has no appetite, which has put his hydration and nutritional status at risk. Rubbing his back and left side. Complains of nausea and has shaking with chills.

Assessment

Fill in the missing words

Q: Assessment: I believe the client has a urinary tract infection as his status has changed – disoriented, drowsy and the characteristics of his urine are not within normal limits. I believe it is a [...] infection based on his signs and symptoms.
A: kidney
Feedback (0 to 99%): that is not the right location - try again
Feedback (100 to 100%): That is correct - clue for later - streps and staphs are not where it's at!

Recommendations

Q: Recommendations: Dr. Zeiger these are the orders I require for Mr. Wei and need to incorporate interventions that are congruent with his plan of care.

When considering the "R" in SBAR select all of the following that apply:
- Urine sample for culture and sensitivity (correct)
- Pharmacological treatment for suspected symptomatic UTI (correct)
- Blood work – CBC and electrolytes (correct)
- Order to irrigate urinary catheter to determine patency (correct)
- Potential of discontinuing the urinary catheter and re-inserting a new one (correct)
- Consult Dietician for nutritional health and hydration (correct)
- Increase frequency of vital sign monitoring to every 4 hours (correct)
- Could you also please assess Phang this afternoon when you are in the facility? (correct)
- Place the client on NPO status
- An order for a diuretic
- An order for intravenous therapy
- Consult to speech language pathology for a swallowing assessment
Feedback (0 to 99%): You have not identified all of the correct answers - try again!
Feedback (100 to 100%): That is correct! Clue for later - look for the E in the P!

Fall stats

Credits: by unknown (Author); licence CC BY 4.0

[Image: picture of clipboard with checklist]

falls risk

Since the client has a change in mentation the nurse will need to complete the Fall Assessment Tool to identify their risk for having a fall.

Falls Stats

20-30% of seniors experience one or more falls each year

Falls cause 85% of seniors' injury-related hospitalizations, 95% of all hip fractures

Fall cost $2 billion a year in direct healthcare costs

Over 1/3 of seniors are admitted to long-term care following hospitalization for a fall

The average Canadian senior had to stay in hospital 10 days longer for falls than for any other cause

50% of all falls causing hospitalization happen at home

bolded numbers

Q: You want to call Mr. Wei's daughter to ask about his falls history.  Use the previous clues to get her number.
- 200-5110 (You missed something!)
- 235-3159 (Look more closely)
- 359-2315 (Correct!: Feedback from the daughter related to falls. “My Dad experienced one fall about a month before he came to live with you but no falls prior to that one. He called me right after it happened. He could not remember what occurred before he fell. He was able to get up on his own and I took him to the doctors to be examined. He did not have any injuries from it – I told the doctor that he seemed wobbly on his feet at times and relied on using the furniture in his home to get around.”)
- 800-5291 (Looks like you missed something)

Falls

physical restraints 1

Q: Routine use of restraints in LTC does not decrease the risk of falls or injuries r/t falls
A: true
If right: That is correct - key words for later are: sensory, bathroom and preventable

Q: Restraints should not be used as a strategy to prevent falls
A: true
If right: That is correct - words for later are: reduce, cluttered and history

Q: In some cases, restraints actually increase the risk of injury
A: true
If right: That is correct! Words for later: five, dementia and hypotension

Q: Using bed and chair alarms is considered a form of restraint to prevent falls
A: false
If right: That is correct - words for later are reach, increases and locked

Falls

Fill in the missing words - you have the clues!

Q: There are total of [...] components in the Morse Fall Risk assessment scale.

Falls are [...].

[...] impairments are one of the risk factors for fall.

Always place the call bell within the patient's [...].

One condition which contributes to patient falls is [...].

A [...] living space is one of the extrinsic factors for a fall.

Beds are to be kept at the lowest position and remain [...] at all times.

Postural [...] can lead to a fall.

Medication management can [...] interactions and side effects that may lead to falls.

As we age our chance of falling [...].

Fall [...] is the strongest risk factor associated with subsequent falls.
A: five; preventable; Sensory; reach; dementia; cluttered; locked; hypotension; reduce; increases; history
Feedback (0 to 99%): You have made some mistakes - try again!
Feedback (100 to 100%): Great job - there was one place you did not go!

Location of infection

Q: What numbers correspond to the likely location of the infection?
- 3279 (Incorrect!: This is not a likely location!)
- 4528 (Try again!: Symptoms of infection in the bladder are: Pelvic pressure Lower abdominal discomfort Frequent, painful urination Hematuria)
- 7510 (Try again!: Symptoms of infection in the urethra include: Burning with urination Discharge)
- 8105 (Incorrect: This is not a likely location.)
- 9436 (That is correct!: Common symptoms for Kidney infection are: Back or flank pain, fever, shaking, chills and nausea / vomiting)

likely diagnosis

Q: Based on the assessment what is the nurse's likely diagnosis?
- Pneumonia (Try again!: Review the assessment results given in the feedback of the previous exercise!)
- Urinary Tract Infection (That is correct!: Cloudy, dark, foul smelling urine with a low urinary output indicates the likelihood of a UTI)
- Wound on coccyx that has become infected (Try again!: Review the assessment results given in the feedback of the previous exercise!)
- Depression related to social isolation (Try again!: Review the assessment results given in the feedback of the previous exercise!)

organism for UTI

Q: The most common organism associated with Catheter-associated UTI [CAUTI] is usually:
- Streptococcus pneumoniae (Try again!: Streptococcus pneumonia is a gram-positive anaerobic bacteria usually found in the respiratory tract)
- Pseudomonas aeruginosa (Try again!: Pseudomonas aeruginosa is a gram-negative aerobic bacterium usually found in the blood and lungs)
- Escherichia coli (You are correct!)
- Staphylococcus aureus (Try again!: Staphylococcus aureus is a gram-positive bacterium usually found in the upper respiratory tract and on the skin)

healthy vs unhealthy factors

Urinary health

Good urinary health is important overall to prevent infection and also, as previously mentioned, because for many older adults at risk attempting to get out of bed to go to the bathroom is one of the most common reasons for falls.

There are many factors that contribute to good urinary health and it is important for you, as the nurse, to be aware of these factors and to share them with your clients.

Healthy vs. unhealthy habits

Choose which items positively affect urinary health and total the numbers on the back.

Q: Good hydration
A: 5

Q: Healthy weight
A: 3

Q: Urinate every one to two hours
A: 7

Q: Do pelvic floor muscle exercises.
A: 2

Q: Wear nylon underwear and loose-fitting clothing
A: 4

Q: Limit alcohol and caffeine beverages
A: 1

Q: Wipe from back to front after urination.
A: 6

Q: Do not smoke.
A: 8

Q: Exercise regularly
A: 9

Q: Constipation
A: 10

predisposing factors

Q: One of the most common predisposing factors for a fall is ______________.
- climbing stairs (Try again!)
- walking outdoors (Try again!)
- going to the bathroom (Correct!: Attempting to get out of bed to use the bathroom is one of the most common predisposing factors for a fall for those at risk which supports the importance of linking healthy nutrition to good urinary wellbeing.)

DAR Note

loop back to client

I have spoken with Mr. Wei and his daughter Patricia to update both of them regarding my conversation with Dr. Zeiger. I explained that I notified the doctor of the changes Mr. Wei is experiencing and we have developed a plan of care that I wanted to share with them to ensure they were in agreement and if there is anything else we can add to the plan. Both are in agreement to proceed. Interventions initiated and completed. Mr. Wei is resting comfortably and now it is time to complete my documentation.

Credits: by unknown (Author); licence CC BY-NC-SA 3.0

[Image: male nurse smiling]

March 1, 2022 1100 | Urinary Function
D | Client states “I am so tired, I don’t feel like doing anything, you can’t make me.  I am not going to eat this food – I have no appetite and I am not thirsty.” Client is not orientated to person, place or time since waking up this morning. Sleeping the last 4 hours and awakens briefly when roused. Increased confusion as the morning has progressed. Indwelling catheter in situ. Draining dark cloudy amber, blood tinged.  Urine has a foul odor. Urinary output 100 mLs over the last 4 hours. Vital signs 37.5°C, 160/90, 90, 18.  Client unable to communicate pain intensity, rubbing his back and left side. Complains of nausea and shaking with chills.------------------------------------------------------------------
A | Attending physician notified of change in client’s condition. Physician will visit client when performing rounds at noon. Urine sample obtained and sent for culture and sensitivity. Catheter irrigated with 50 mLs of NaCL, patency of catheter confirmed. Encouraged and supported client to drink 150 mLs of water. Provided calm environment to keep client comfortable. Increase frequency of vital sign monitoring to Q4h and prn. Fall Assessment tool completed. Family notified of change in client’s condition. -------------------------------------------------------------------------------------------------------------------
R | Client tolerated irrigation of catheter. Will continue monitor neurological status as well any changes in vital signs. Observe urinary output for amount and characteristics. Await results of urine C+S and call physician with results. ----------------------------------Joe Belgrave RN

Total of healthy behaviours

Q: What was the total of all of the numbers on the back of the healthy behaviour cards?
- 28 (Great job!: You have identified the key factors!)
- 32 (Not quite!: Wearing nylon underwear and loose-fitting clothing is actually not beneficial!)
- 35 (try again!: Urinating every one to two hours is not healthy.)
- 39 (Try again!: Some of these factors are not healthy behaviours!)

DAR question

Q: Which of the following CNO standards were incorporated into the DAR note.  Select all that apply:
- Charting is clear, comprehensive and accurate (correct)
- Includes judgment and critical thinking used by the nurse (correct)
- Communicates client health information that is current (correct)
- Includes client outcomes (correct)
- Captures communication to a team member (correct)
- Assessment, planning, implementation and evaluation are incorporated (correct)
- Objective and subjective data captured (correct)
- Identifiable signature and designation (correct)
Feedback (0 to 99%): You are missing something!
Feedback (100 to 100%): You selected all - and you are correct! The mandarin symbol for escape is 逃

pick the correct symbol

Q: What is the mandarin symbol you need to get out?
- 你好 (Try again!: This is the symbol for hello!)
- 逃 (You are correct!)
- 再见 (Try again: This is the symbol for good-bye but you are not out yet!)

You have escaped

Escaped

Congratulations!  You have escaped!

The next slides will review the learning concepts presented in this activity.

Credits: by unknown (Author); licence CC BY-NC-ND 3.0

[Image: picture of an open door with the sky beyond]

Communication

Communication/language barriers

Language barriers have the potential to impact the nurses’ ability to communicate successfully with their clients which can lead to safety issues in relation to providing appropriate care and being able to meet the client’s needs. Clients who have Limited English Proficiency (LEP) can experience negative outcomes related to the care their receive.

Strategies to augment communication with LEP are:

- Medical Interpreters – in person or by phone.
- Professional staff members who speak other languages fluently.
- Creating a communication board of commonly used phrases in the client’s language.
- Family/friends that can interpret.
- Organizational sanctioned apps.

Nurse's role

Nurse’s role in assigning care to an Unregulated Care Provider (UCP)

The College of Nurses of Ontario (2008) states “assigning is the act of determining or allocating responsibility for particular aspects of care to another individual. This includes assigning procedures that may or may not be a controlled act. Ideally, a range of care needs, rather than specific procedures, are assigned. Depending on the nature and responsibilities of their positions, nurses with the necessary knowledge and judgment may assign care to a UCP. In some instances, the delegator or the teacher may also assign care to a UCP” (p. 7).

From: https://www.cno.org/globalassets/docs/prac/41014_workingucp.pdf

UTI

Urinary Tract Infections, CAUTI

Urinary tract infections (UTI):

- Involve any part of the urinary system [urethra, bladder, ureters, and kidneys].
- Are the most common type of healthcare-associated infection.
- Are associated with prolonged use of a urinary catheter [CAUTI] and the catheter should be only be used for appropriate reasons and discontinued as soon as it is no longer required.
- If left untreated can lead to acute or chronic kidney infections, kidney failure and sepsis.

From: https://www.cdc.gov/hai/ca_uti/uti.htm

UTI’s in the Elderly Population:

- May present differently due to an aging immune system and inability to communicate the symptoms they are experiencing.
- Nurses need to assess for atypical signs and symptoms such as a change in their client’s mental state such as; confusion or delirium, agitation, hallucinations, unusual behavioral changes, poor motor skills or loss of coordination, dizziness and falling.

Another aspect to keep in mind is that the elderly population is prone to asymptomatic bacteriuria [bacteria in the urine with no signs or symptoms of a urinary tract infection]. Most do not develop symptomatic UTI's and antibiotic therapy would not beneficial and can potentially lead to more problems for the individual.

From:https://www.agingcare.com/articles/urinary-tract-infections-elderly

Falls

- Unintentional falls are one of the most common causes of hospitalizations/ER visits for injury and trauma.
- Hip fractures are the most common type of injury due to falls in those 65 and older and are most likely to be hospitalized.
- The average hospital stay after a fall was 14.3 days [2016-17] compared with 7.5 days for the average of all hospitalizations.

From: https://www.cihi.ca/en/exercise-caution-canadians-frequently-injured-in-falls

Restraints

- Nurses are accountable for providing, facilitating, advocating and promoting the best possible care and to take action when client safety and well-being are compromised, including the decision to apply restraints.
- Restraints are only utilized for the shortest time when prevention, de-escalation and crisis management strategies have not achieved client safety.
- The client, their family and substitute decision makers must be actively involved.
- Nurses are accountable for documenting nursing care provided [assessment, planning, intervention and evaluation].
- Restraints can increase the risk of medical, psychological and functional complications.

From: https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/restraints/

Patient Restraints Minimization Act, 2001 [Bill 85]

- Is to minimize the use of restraints on clients and to encourage hospitals and facilities to use alternative methods, whenever possible, when it is necessary to prevent serious bodily harm by a client to himself/herself or to others c.16, s.3.

From: https://www.ontario.ca/laws/statute/01p16

A few key points made by RNAO (2012) related to Promoting Safety- Alternative Approaches to the Use of Restraints are:

- Prevention of restraint use with a thorough assessment and the implementation of alternative approaches is utilized to prevent restraint use.
- When restraint use is deemed unavoidable, the least restrictive form of restraint is used for the shortest duration of time.
- The use of restraints is temporary and alternatives must continue to be considered.

From: https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

Charting Principles: DAR and SBAR

Written Nursing Documentation:

- Needs to be clear, comprehensive and accurate as it facilitates client safety and effective nursing care.
- Provides a legal record of the nurse’s judgment and critical thinking used to client care.

From: https://www.cno.org/globalassets/docs/prac/41001_documentation.pdf

SBAR

Situation Background Assessment and Recommendations:

- Facilitate and strengthen communication of clinical information between health care providers to promote safe client care.
- Is a structured communication tool, which has demonstrated positive outcomes in reducing adverse events in hospital settings.
- Can be modified to most clinical settings.
- Requires educational training.

From: https://safetyinhealth.biomedcentral.com/articles/10.1186/s40886-018-0073-1

Let untreated

left untreated

Drag the words into the correct boxes

Q: If a urinary tract infection is left untreated what can happen?
• Narrowing of [...] in men
• Recurrent [...]
• Increasing chance of developing [...]
• Long term [...] damage
A: urethra; infections; sepsis; kidney
Feedback (0 to 99%): Try again
Feedback (100 to 100%): Great job - no "pseudonym" here!

Navigation

Here are some pointers for navigating the escape room:

You can use the Proceed and Back buttons in the top right corner to navigate from one section to the next.  To view slides you will use the arrows at the bottom of the screen.  You have the ability to go back to review previous slides / sections.

When you complete an activity you may need to scroll down and hit the Check button at the bottom of the page for your results and the next clue.

In some cases you will be given clues to use later in the escape room so you may want to have a paper and pen ready to make notes!

We hope you enjoy this learning activity!

Thank you for participating in our Escape Room Exercise!

Credits: Blue Ribbon; by unknown; licence CC BY-NC 3.0